All children, even the healthiest, have preventive and acute health care needs. Moreover, a growing number of children are chronically ill, with preventive, acute, and ongoing care needs that may be much more demanding than those for healthy children.

Because children are unable to care for themselves, their parents are expected to provide a range of health care services without which the current health care system for children would not function. Under this “shadow health care system,” parents or parent surrogates often need to be with the child, a requirement that can create difficulties for working parents, particularly for those whose children are chronically ill. How federal, state, and employer policies and practices mesh with the child health care needs of families is therefore a central issue in any discussion about work and family balance.

In this article Mark Schuster, Paul Chung, and Katherine Vestal describe the health care needs of children; the essential health care responsibilities of parents; the perspective of employers; and the existing network of federal, state, and local family leave benefits that employed parents can access. They also identify current gaps in policies that leave unmet the needs of both parents and their employers.

The authors suggest the outlines of a national family leave policy that would protect the interests of parents and employers. In essence, such a policy would build on the federal Family and Medical Leave Act, which gives some workers time off with no advance notice required and no loss of job or health insurance. But it would also include elements of California’s Paid Family Leave Insurance, which expands coverage to more workers and provides partial pay during leave. Employers could be given some financial protections as well as protections against employee fraud and abuse. Such a policy, the authors conclude, would help to provide security to parents, minimize effects on employers, raise societal expectations for family-friendly work environments, and help maintain the parental shadow system of care on which health care professionals depend.